acupunctura - medicina

7/29/2019 ACUPUNCTURA - medicina

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NCAHF Position Paper on Acupuncture

Summary

Acupuncture involves the stimulation of certain points on or near the skin by the insertion of needles or by other methods. Ithas been used as a treatment in Asia for several thousand years but has not been proven effective by modern standards.Acupuncture is being promoted as both an "alternative" treatment and an adjunct to standard treatment. In China, it was bannedin 1929 but underwent resurgence in the 1960s during the Cultural Revolution. In the United States, it is used mainly for painrelief. Some states permit only licensed physicians to perform acupuncture, while others license lay persons as well. Whileacupuncture organizations are trying to standardize training, researchers are still attempting to determine whether acupunctureis effective.

NCAHF believes:1. Acupuncture is an unproven modality of treatment;2. Its theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to

present scientific knowledge;3. Research during the past twenty years has failed to demonstrate that acupuncture is effective against any disease;4. Perceived effects of acupuncture are probably due to a combination of expectation, suggestion, counter- irritation,

operant conditioning, and other psychological mechanisms;5. The use of acupuncture should be restricted to appropriate research settings;6. Insurance companies should not be required by law to cover acupuncture treatment; and7. Licensure of lay acupuncturists should be phased out.

Theory and Practice

Acupuncture is based on ancient Chinese medical philosophy, which views illness quite differently than does contemporaryscience. (Ref.1) In ancient China, diseases were not systematically described or classified. (Ref. 2) Internal organs, which werefelt to be intermediaries between the body and nature, were assigned qualities representing emotional states, colors, andseasons. Some organs, such as the "triple warmer," were imaginary. There were no concepts of modern physiology,

biochemistry, nutrition or mechanisms of healing. There was no knowledge of the existence of cells, the circulation of theblood, the function of nerves, or the existence of hormones. Dissection of the human body was not done, so that evenknowledge of anatomy was incomplete.

Diagnosis

Traditional Chinese diagnosis does not correlate with modern scientific concepts. An ill person was considered out of balancewith nature and its two opposing forces, yin and yang. Yin represented the feminine, passive, or accepting qualities, and yangthe masculine, aggressive, or forceful ones. Diseases were not described or named. Diagnoses were made by examining the

pulse (of which there were supposedly six variations) and the tongue, which was said to vary in appearance with certaindisease states. Today we know that there is only one pulse, which corresponds to the pumping action of the heart, and that theappearance of the tongue is seldom a clue to the diagnosis of disease in other parts of the body.Traditional Chinese treatments were directed at re-establishing "balance" and "harmony," which supposedly occur assymptoms improve. Since there was no formal study of diseases or description of their natural history, the ancient Chinesecould rarely determine how an illness actually improved. Treatments were chosen by trial and error, and perpetuated by

personal experience. Since there were no scientific criteria for success or failure, the judgment that "healing" had taken placewas based on the word of the therapist or the patient. The natural course of the disease usually took place unaltered bytreatment.Acupuncture points were assigned to "meridians" on the surface of the body. These supposedly represent channels throughwhich flows the life force, "Ch'i" or "Qi.." Fourteen channels were said to permit maximal influence on the flow of Ch'i insidethe body. Insertion of needles at the designated points was said to increase or decrease the flow of Ch'i to achieve a morenormal and harmonious state. Originally there were 365 acupuncture points, corresponding to the days of the year, but thenumber identified by proponents during the past 2,000 years increased gradually to over 2,000. (Ref. 3)The life force, Ch'i, has no basis in human physiology. The meridians are imaginary; their locations do not relate to internalorgans, and therefore do not relate to human anatomy. Acupuncture points are also imaginary. (Various acupuncture chartsgive different locations for the points.) These fanciful concepts continue to form the basis of modern acupuncture therapy eventhough extremely sophisticated methods are used to measure its reputed biochemical effects. Although scientific methods may

be applied to biochemical studies, many published reports are based solely and uncritically on clinical anecdotes and tradition.

(Ref. 4)Acupuncture is not difficult to perform. It involves a variety of procedures performed at "acupuncture points" on the skin. Themodalities include:

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Insertion of needles. Fine stainless steel needles are inserted to varying depths with an in-and-out twirling motionuntil there is a local feeling of numbness (a temporary reaction to injury). They are left in place for about twentyminutes, then removed.

Burning of vegetable fibers (moxibustion). (Ref. 5)

Suction by cups containing heated air (cupping)

Injected solutions

Low-voltage current applied to needles (electroacupuncture), a relatively recent developmentOther variations and offshoots include:

Trigger point therapy. Some proponents claim that acupuncture points coincide with "trigger points' - areas at whichthe injections of a local anesthetic can relieve regional pain. However, trigger points are not anatomicallydemonstrable and vary from individual to individual. Any effects from acupuncture are likely to be due to nonspecificmechanisms rather than location of the "points".

Auriculotherapy. This is based on the notion that the body and organs are represented on the ear . (Ref. 6) Needles areplaced in the imaginary points representing the diseased organs. There is no scientific evidence that these points existor that auriculotherapy has any therapeutic value. (Ref. 7)

Staplepuncture. Staples are placed at acupuncture points on the ear, typically to aid smoking cessation or drugwithdrawal.

Acupressure, firm digital pressure on trigger points or acupuncture points.

"Touch for Health," developed by a chiropractor using acupressure points and an unreliable muscle-testing method("applied kinesiology'). The therapist claims to diagnose nutritional and glandular "deficiencies" that are then

"corrected" by manipulation or nutrition supplements.

Proposed Mechanisms of Action

The following mechanisms have been proposed to explain acupuncture's presumed action on pain:

Release of endorphins (narcotic-like substances produced by the body). Naloxone, which reverses the effects ofadministered opiates, has been reported to reduce the analgesia produced by acupuncture. However, some studiesshow no reversal. Even if endorphin release were a real mechanism for acupuncture action, there are simpler and noninvasive ways to cause endorphin release.

The "gate theory." This suggests that if pain fibers carry impulses from an acupuncture site, impulses from a painfulbody organ will be unable to reach the brain. However, there is no anatomical or physiological basis for thisexplanation.

Diversion. Attention can be diverted from a symptom by stimulating or irritating another part of the body.

Psychological mechanisms. These include suggestion, operant conditioning and other psychological mechanisms, anyof which may be involved in the placebo effect.

Current Use in China

Acupuncture anesthesia has been observed by Western anesthesiologists and other medical scientists. American interest wastriggered in 1972 by a rumor that New York Times reporter James Reston had received acupuncture anesthesia for anappendectomy while visiting China. Actually, he had had standard anesthesia and received acupuncture for postoperativecramps.Despite popular claims, acupuncture anesthesia is not used for emergency surgery. It is not used routinely, but only on the 10%to 15% of people who are suggestible and perhaps easily hypnotizable. It is seldom used for abdominal or chest surgery, inwhich muscle relaxation is necessary (general anesthesia as done in the West is used.) Moreover, when acupuncture is used forsurgery, the patient is usually medicated with narcotics and other standard drugs. (Ref. 8-10)

For other medical conditions, acupuncture and herbalism are regarded as elective procedures. Of the forty-six major medicaljournals published by the Chinese Medical Association, none is devoted to acupuncture, herbalism, and their variants. Thegreat majority of papers are about scientific, rather than traditional Chinese methods. Few articles concern the integration ofacupuncture with modern treatments. Reports of acupuncture successes are often not accompanied by reliable measurements.

Scientific Status

The World Health Organization has listed forty conditions for which claims of effectiveness have been made. They includeacute and chronic pain, rheumatoid and osteoarthritis, muscle and nerve "difficulties," depression, smoking, eating disorders,drug "behavior problems," migraine, acne, ulcers, cancer, and constipation. Some chiropractors and psychologists have madeunsubstantiated claims to improve dyslexia and learning disorders by acupressure. However, scientific evidence supportingthese claims is either inadequate or nonexistent.

Experimental Difficulties

The following should be considered when evaluating an acupuncture research paper:

Symptom relief is difficult to assess because there is no objective standard of measurement.

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Double-blind studies comparing the insertion of needles at acupuncture points and at other points ("shamacupuncture") are difficult to design. If an experienced acupuncturist locates the points, the practitioner's expectationsmay be transmitted to the patient. If an inexperienced person inserts the points, misplaced needles may undermine theresults. Moreover, practitioners may differ about the location of the points, and so many points have been postulatedthat it may be difficult to find a patch of skin that has not been labeled an "acupuncture point."

Chronic pain is often cyclic, with periods of relief. Since people often request help when their pain is most severe,spontaneous improvement may occur independent of the treatment. (Ref. 11)

Most acute (recent onset) pain improves with time and no intervention. Thus, people may report improvement of

symptoms from any intervention, even if the method has no effect. There is general agreement that 30% to 35% of subjects' pain improves from suggestion or placebo effect alone. Thus,

measuring a small difference between placebo and acupuncture requires a large number of subjects (several hundredin each group) to show as little difference as 25%.

People who volunteer for acupuncture may have a conscious or unconscious bias toward the procedure and thus maybe more prone to suggestion.

Proponents of a method tend to report trials showing positive effects, and not to report trials showing no effect ornegative effects.

Despite these difficulties, well controlled trials can be carried out by using: 1) unbiased subjects, 2) random assignment ofsubjects into treatment and control groups, 3) blinding of both therapists and subjects, 4) blinded evaluations by separateobservers, 5) a reliable diary or reporting system if symptom relief is the end point, 6) adequate period of follow-up past thetime of treatment, 7) enough subjects to test the significance of any difference found. Few studies have satisfied these

requirements.Scientific Reviews

Richardson and Vincent analyzed 28 studies of effect of acupuncture on pain, all published between 1973 and 1986 in Englishlanguage peer-reviewed journals. Fifteen showed no difference in effectiveness between acupuncture and control groups.Thirteen showed some effectiveness for acupuncture over control groups, but not all controls were the same. (Some werecompared to sham acupuncture, some to medical therapy, etc.) Overall, the differences were small. (Refs. 12-13)The NCAHF Task Force on Acupuncture evaluated the above studies, as well as more recent ones, and found that reported

benefits varied inversely with quality of the experimental design. The greater the benefit claimed, the worse the experimentaldesign. Most studies that showed positive effects used too few subjects to be statistically significant. The best designedexperiments - those with the highest number of controls on variables - found no difference between acupuncture and controlgroups.In 1989, three Dutch epidemiologists reported similar conclusions about 91 separate clinical trials of acupuncture for various

disorders. They also found that the stricter the controls, the smaller the difference between acupuncture and control groups.(Ref. 14)Acupuncture is being used in drug and alcohol rehabilitation programs. Because there are serious flaws in the way studies onrehabilitation have been performed, the results cannot be considered valid.A successful medical procedure should be consistently effective in a large majority of trials, and be repeatable in the hands ofmost therapists. Acupuncture does not satisfy these basic criteria.The American Medical Association's Council on Scientific Affairs stated in a 1981 report that since acupuncture is anexperimental procedure, it should be performed only in research settings by licensed physicians or others under their directsupervision. The report urged state medical societies to seek appropriate laws to restrict the performance of acupuncture toresearch settings. (Ref. 15)

Acupuncture Training

Acupuncture is not part of the curriculum at most American medical schools. Nevertheless, proponents say that severalthousand physicians in the U.S. and Canada use it in their practices. The American Academy of Medical Acupuncture ofBerkeley, California, sponsors courses for physicians given under the auspices of medical schools, including UCLA, JeffersonMedical College, and Temple University. The University of Hawaii also sponsors a course. Tuition is as much as $3,600 for aone-week course.Lay persons who perform acupuncture may use the following degrees and/or titles:Certified Acupuncturist ( C.A.): This title can be granted to lay persons by a state licensing board after qualifyingexamination.Master Acupuncturist (M.A.): A title granted to some licensed acupuncturists in certain states.Diplomate of Acupuncture (Dpl.Ac.): Certified by an organization called the National Commission for the Certification ofAcupuncturists (NCCA).Oriental Medical Doctor (O.M.D. or M.O.D): This is not a recognized degree.Doctor of Philosophy (Ph.D): No American school granting this degree for acupuncture is accredited. One such school is theCenter for Chinese Medicine, Monterey Park, California. Its 250-hour course lasts about 30 days and costs $3,500.

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Hazards

The frequency of complications of acupuncture needling is not known, since no survey has been done. Nevertheless, seriouscomplications occur even in experienced hands and are reported in medical journals. These include fainting, local hematoma(bleeding from punctured blood vessel), pneumothorax (punctured lung), convulsions, local infections, hepatitis B (fromunsterile needles), bacterial endocarditis, contact dermatitis, and nerve damage. The herbs used by acupuncture practitionersare not regulated for safety, potency or effectiveness. There is also the risk that a lay acupuncturist will fail to diagnose adangerous condition.

Legal Status

All states permit acupuncture to be performed - some by physicians only, some by lay acupuncturists under medicalsupervision, and some by unsupervised lay persons. Seventeen states permit lay acupuncturists to practice without medicalsupervision. In 1990 the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicinewas recognized by the U.S. Secretary of Education as an accrediting agency. [Note: Such recognition is not based upon thescientific validity of what is taught but upon other criteria.]Many insurance companies cover acupuncture treatment if performed by a licensed physician, but Medicare and Medicaidgenerally do not. Acupuncture needles are considered investigational (unapproved) devices by the U.S. Food and DrugAdministration.In California, where acupuncture is being offered for hypertension, obesity, heart failure, arthritis, and smoking and drugwithdrawal, the acupuncture law permits acupuncturists to advertise treatment for any ailment except cancer, as long as a cureis not promised. Cancer treatment is prohibited by the California Cancer Law.

Every ethnic group has its own set of medical customs not supported by science. Some proponents argue that Asianpopulations should have access to their traditional remedies, however ineffective and unscientific they may be. This question isdifficult to resolve because it conflicts with the modern principle of consumer protection based on reliability and fulfillment of

promised claims. Cultural activities are generally tolerated provided that they do not conflict with laws for the generalpopulation and are not dangerous. Chaos would result if the populace could not be protected from misrepresentation, and ifinsurance companies were forced to pay for all traditional foreign methods.

NCAHF Recommendations

The National Council Against Health Fraud believes that after more than twenty years in the court of scientific opinion,acupuncture has not been demonstrated effective for any condition. We therefore advise the following:

To Physicians:

Note that the scientific literature provides no evidence that acupuncture can perform consistently better than a placebo inrelieving pain or other symptoms for which it has been proposed. Most reports claiming positive and statistically significantresults for acupuncture are flawed by biased patient selection, poor controls, lack of blinding, or insufficient numbers. There isno physiologic rationale for why acupuncture should work other than for its placebo or counter-irritant and distracting effects.For these reasons, acupuncture should not be offered without full informed consent, reminding patients that acupuncture isexperimental, has not been proven more effective than a placebo, and has some risk of complications.

To Consumers:

Beware of misleading and untrue statements made for acupuncture. Some states do not regulate such claims. Because laws arepolitical tools, not scientific ones, the political process often responds to pressures independent of scientific evidence.Acupuncture cures nothing. It may relieve symptoms with the frequency of a placebo. It may be harmful. Consumers wishingto try acupuncture should discuss their situation with a knowledgeable physician who has no commercial interest.

To Legislators:Acupuncture licensing should be abolished. Public display of unaccredited degrees by individuals offering any form of healthcare should be banned. Insurance companies, HMOs and government insurance programs should not be forced to coveracupuncture unless scientific evidence demonstrates that it has value.

The National Council Against Health Fraud, Inc.

NCAHF is a private nonprofit, voluntary health agency that focuses upon health misinformation, fraud and quackery as public healthproblems. Its funding is derived primarily from membership dues, newsletter subscriptions, and consumer information services. NCAHF'sofficers and board members serve without compensation. NCAHF unites consumers with health professionals, educators, researchers,attorneys, and others who believe that everyone has a stake in the quality of the health marketplace. NCAHF's p ositions on consumer healthissues are based upon principles of science that underlie consumer protection law. Required are: (1) adequate disclosure in labeling and other

warranties to enable consumers to make proper choices; (2) premarketing proof of safety and efficacy for products and services that claim toprevent, alleviate, or cure any disease or disorder; and, (3) accountability for those who violate consumer laws.For more information, write: NCAHF, P.O. Box 1276, Loma Linda, CA 92354-1276; Fax: 909-824-4838. Donations to NCAHF are tax

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deductible under IRS tax code 501 (c)(3).

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